EUS-guided hepaticogastrostomy in multimetastatic liver disease - an effective approach for biliary drainage that may complement ERCP

A 36-year-old male was diagnosed with a metastasized colon adenocarcinoma causing obstructive jaundice. Magnetic resonance cholangiography showed a dominant lesion causing hilar stenosis. The patient was submitted to endoscopic retrograde cholangiopancreatography (ERCP), nevertheless it was just possible to place a single uncovered self-expandable metallic stent (SEMS) in the right lobe. Although cholestasis significantly improved, safe levels for oncologic therapy were not reached. EUS-guided hepaticogastrostomy was proposed to complement ERCP biliary drainage. Using a forward-viewing echoendoscope and a transgastric approach, EUS-guided puncture of a dilated left intrahepatic duct at segment III was accomplished with a 19G needle (EchoTip ProCore®) that allowed passage of a 0.035 guidewire. A 6F cystotome and biliary dilators (5Fr+8.5Fr) were used for needle tract dilation. A partially-covered SEMS (GIOBOR™ 8x100mm) could be deployed under endoscopic and fluoroscopic control, being placed 3cm inside the gastric lumen. No associated complications were observed after the procedure.